Appeals and Grievances
What if you have a problem?
If you have a problem or concern, you should call Member Services at 1-800-450-1166 (TTY/TDD 711), 8 a.m. to 8 p.m., 7 days a week.
If we deny a health care service or claim in whole or in part, there are things you can do. You, or your representative can ask us to review our coverage decision. There are different types of appeals to the plan:
- An appeal about Medicare Part C medical care or services is called plan "reconsideration."
- An appeal about a Medicare Part D drug is called a plan "redetermination."
When we get your request to review the coverage decision, it is reviewed by people at our organization. These people were not a part of the original decision. This helps to make sure that we will give your request a fresh look.
How soon must you file an appeal?
You must file the appeal request within 60 calendar days of the date that is on the notice of our coverage decision. You may file your request by mail, fax, or phone. We may give you more time to file if you have a good reason. You can look at your Evidence of Coverage, Chapter 9 (PDF — June 12, 2019), for more information on how to file an appeal. You can also call Member Services at 1-800-450-1166 (TTY/TDD 711), 8 a.m. to 8 p.m., 7 days a week.
- Spanish Evidence of Coverage (PDF — June 17, 2019).
A grievance is a complaint. It does not involve problems related to:
- Approving or paying for Medicare Part C and Medicare Part D drugs.
- Medical care or services.
- Having to leave the hospital too soon.
- Skilled nursing facility (SNF), home health agency (HHA), or comprehensive rehabilitation facility (CORF) services ending too soon.
What types of problems would lead you to file a grievance?
- You have problems with the service you get from Member Services.
- You feel that you are being encouraged to leave (disenroll from) the plan.
- You do not agree with our decision not to give you a "fast" decision or a "fast" appeal.
- We don't give you a decision within the required time frame.
- We don't give you required notices.
- You believe our notices and other written materials are hard to understand.
- You feel that you wait too long for prescriptions to be filled.
- You experience rude behavior by network pharmacists, physicians, or providers. This includes staff in pharmacies, physician offices, or hospitals.
- We fail to give your case to the independent review entity. You do not get a decision on time because of this.
- You do not feel you got the best medical care or services you could get. This includes care during a hospital stay.
- You feel that you wait on the phone, in the waiting room, or in the exam room too long.
- You have a problem getting an appointment when you need it. You wait too long for them.
- The doctor's offices, clinics, or hospitals are not clean or in good condition.
Contact information for appeals and grievances
Keystone First VIP Choice (HMO SNP)
Appeals, Grievances, and Complaints
PO Box 80109
London, KY 40742- 0109
Phone: 1-800-450-1166 (TTY/TDD 711), 8 a.m. to 8 p.m., 7 days a week.
Appointment of Representative (AOR) form (PDF) — A request can be made by a family member, friend, or other party. This person must show legal authority, such as a medical power of attorney.
Other important information
You can see a total number of grievances, appeals, and exceptions filed with our plan. You can do this by contacting the Appeals and Grievances Unit. See the contact information above.
You are able to file a grievance or provide feedback directly to Medicare about our plan using the Medicare Feedback and Complaint Form.